Prior authorization is the one process CMS — and every provider — is watching most closely. Can yours stand the scrutiny?
Agents at work in Utilization Management (5)
Answering member and provider questions 24/7 — no hold time, no headcount.
Resolve the bulk of your call center volume, with zero hold time — whether at 2 a.m. or during open-enrollment surges.
Inbound member and provider calls answered 24/7:
- eligibility and benefits questions
- claim status
- prior authorization status
- appeal and grievance status
The caller is HIPAA-authenticated, served in their language, and answered from live core-system data.
Operations leaders: Reduce overhead costs and maximize your team’s efficiency by automating routine, high-volume inquiries. Now your call center can easily manage sudden call spikes without the cost of hiring temporary staff. Free up your human agents to handle the complicated or sensitive issues like complex claim denials or appeals. When human empathy is made available, instead of being burdened by routines easily answered by conversational AI, member experience is more positive; they feel cared for, and you benefit.
Member experience leaders: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey asks your members, “In the last 6 months, how often did customer service at your health plan give you the information or help you needed?” They can answer with praise because they get their answers immediately.
The right letter, text, email, or call — triggered automatically, delivered compliantly.
The Omni-Channel Notification Agent automates the regulated communications that plans must send across Care Management (CM), Utilization Management (UM), Appeals and Grievances (A&G), and Claims.
Automate regulated communications in compliance — mail, SMS, email, and AI voice:
- determination letters
- acknowledgments
- status updates
- resolution notices
Each communication is triggered by a case event, generated from an approved template, delivered in the member’s language, and timestamped for compliance.
Guarantee adverse determinations go out:
- Within the regulatory window
- Expedited acknowledgments happen in hours
- Without hand-generating correspondence by your staff
Plans see roughly 75% time savings on notification workflows. Now you can eliminate the missed letters that plague audits.
From any channel to open case in 2 minutes — classified, verified, and triaged.
Imagine what’s possible in under 2 minutes. The Intake Agent turns a request — fax, letter, phone call, web portal, or email — into a structured, classified UM, A&G, or Claims case. In no time at all, you have a structured, classified UM, A&G, and Claims case.
The Intake Agent automates 95% of your intake process:
- classifies request type
- AOR documentation verified
- expedited requests flagged
- each case routed to the right queue
Clear the intake backlog that’s putting you at risk. Before a case even opens, you’ll catch expedited appeals on arrival — no more days later in a mailroom queue. Circumvent intake staff redeployment by automating upon receipt.
The clock starts at receipt, making automated intake a plan’s single highest-impact step toward timeliness. Trigger an automated workflow from receipt, and the clock stops being the enemy; it becomes the reward.
Full member clinical picture, summarized in seconds.
Find the clinical story with complete, real-time data. The Clinical Summary Agent builds clinical summaries from every available source:
- Claims
- UM history
- care management
- call notes
- medical records
Clinical summaries are tailored to whoever needs them:
- care managers preparing outreach
- medical directors reviewing UM cases
- A&G coordinators assembling appeal files
Summaries are CMS Interoperability compliant and cut preparation time by as much as 80%. Eliminate hours of clinical staff rebuilding member histories from fragmented systems. Now you can give every reviewer a consistent evidence picture, and accelerate any workflow that starts with “What’s the clinical story here?”
Clinical criteria applied automatically — recommendations with a confidence score.
Do your clinical reviewers have complete, criteria-mapped case files? Or are they working through a stack of faxed records?
With the UM Evidence & Recommendation agent, the clinical evidence is aggregated for each prior authorization; it applies InterQual/MCG criteria and your GoldCarding rules, and generates a determination recommendation with a confidence score.
Accelerate clean approvals:
- Give members and providers answers in hours.
- Apply consistent criteria across every reviewer and shift.
- Focus physician time only on genuine borderline cases.
- Produce documentation that stands up to CMS scrutiny and provider disputes.
Plans see roughly 70% savings on evidence assembly and review prep.
Faster prior authorization
Prior authorization is the bottleneck members and providers feel most — and the one CMS is watching most closely under new interoperability and turnaround mandates.
CareInsight UM turns it from a manual queue into an AI-driven pipeline:
Consistent, defensible decisions
Every determination carries a complete evidence trail, so when CMS, a state regulator, or a provider challenges a decision, the documentation is already there.